Fillable POD Registration Form CT 1-20-2016a Fillable - POD Registration Form CT 1-20-2016 fillable

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POD Registration Form CT 1-20-2016a Fillable - POD Registration Form CT 1-20-2016 fillable

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Country of origin: US
File type: PDF

U.S.A. forms for Town Of Bethel, CT

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Address: Home Phone Number: _______________________
Street City/Town State Zip Code Cell Phone Number: _______________________
LIST NAME BELOW
AND
ANSWER ALL QUESTIONS (1-4)
FOR
EACH PERSON IN HOUSEHOLD
PLEASE PRINT
1
Does person have
known life-
threatening allergies
to Doxycycline or
other “-cycline”
drugs?
Is person pregnant?
2
Does person
have difficulty
swallowing pills?
Is person less
than 9 years old
AND less than
90lb?
3
Any known Life-
threatening allergies
to Ciprofloxacin or
other “floxacin”
drugs?
History of seizure or
epilepsy?
Myasthenia gravis?
Taking Tizanidine?
4
Does this person
have difficulty
swallowing pills?
Is person less
than 9 yrs old
AND less than
62lbs?
STAFF USE ONLY:
Do Not Write in These Two Columns
POD/CLINIC LOCATION:
DATE: ___________
Medical Screener
Initials:________
Dispenser
Initials: _____
First Name
(List yourself first)
Last Name
If yes to ANY question above, select Yes in column below
If No to ALL, select No in column below
.
Circle medicines and
dose and/or special
instructions for each
person
For each bottle
dispensed, place
med label in boxes
below
1.
D C OTHER*
100 500 ____
Place Medication
Label here
2.
D C OTHER*
100 500 _____
Place Medication
Label here
3.
D C OTHER*
100 500 _____
Place Medication
Label here
4.
D C OTHER*
100 500 _____
Place Medication
Label here
5.
D C OTHER*
100 500 _____
Place Medication
Label here
6.
D C OTHER*
100 500 _____
Place Medication
Label here
7.
D C OTHER*
100 500 _____
Place Medication
Label here
Instructions for Medical Screener:
Follow the instructions to the right for each individual
This form assumes there is insufficient Cipro
suspension to treat all children <9 yrs old.
If no, review
Q2.
OR
If yes, skip to
Q3
If no, circle
D100 &
STOP
OR
If yes, circle
OTHER,
write “DCI“
& STOP
If no, review
Q4.
OR
If yes, Direct
person to
Medical
Consult &
STOP
If no, circle
C500 &
STOP
OR
If yes,, circle
“OTHER”,
write “SUSP”
& STOP
**OTHER:
DCI = Doxycycline Crushing
Instructions
SUSP = Ciprofloxacin
Suspension with dosing
instructions
MC = Medical consult
Rev 1-9-2015
PODRegistrationForm
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POD Registration Form CT 1-20-2016a Fillable - POD Registration Form CT 1-20-2016 fillable

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Completed 11 July 2020

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